Infections In Portugal Research Articles

The epidemiology of chlamydia, gonorrhoea and syphilis in Portugal: where do we go from now?

Abstract Chlamydia (CT), gonorrhoea (NG) and syphilis (TP) infections are rising and have an important burden in the EU/EEA. This study aims to describe the epidemiology of these infections in Portugal, between 2015 and 2018, in order to set a baseline for the recently created National Strategy for STI Control and to generate hypothesis on areas for improvement. We analysed data from the national system of epidemiological surveillance (SINAVE®) and described all probable and confirmed cases of CT, NG and TP notified in Portugal between January 1st, 2015 and December 31st, 2018.This reports the overall case evolution as well as specific characteristics of different groups. Throughout the analysed 4-year period there were 1267 cases of CT, 1917 of NG and 3240 of TP (probable and confirmed). Of CT cases, 70% (n = 891) occurred in males, 66.3% (n = 840) in people aged 18-35, 52.9% (n = 670) in heterosexuals and 42.9% (n = 543) in men who have sex with men (MSM). Of NG cases, 87.9% (n = 1686) were males, 90.8% (n = 1741) were <45 years-old and 51.2% (n = 982) were MSM. Of TP cases, 76.0% (n = 2462) were males, 64.8% (n = 2101) were <45 years-old, 41.1% (n = 1333) were heterosexuals and MSM accounted for 39.9% (n = 1294). The notified cases have doubled from 2015 to 2018 (1159 to 2354) and tripled in MSM (440 to 1312), with a 7.9, 4.1 and 1.6-fold increase in CT, NG and TP, respectively. For each infection, symptomatic cases contributed to 42.9% (CT), 14.6% (NG) and 81.9% (TP) of the overall. In similarity to European trends, CT, NG and TP infections seem to be rising in Portugal. Changes in patient behaviour, clinical practice, screenings, settings of diagnosis and notification should be further explored to better understand this trend, including clinical features. From our results, MSM and people aged <45 should be prioritised within the National Strategy for STI Control. A surveillance system evaluation could be considered for sensitivity and usefulness. Key messages The number of chlamydia, gonorrhoea and syphilis reported cases in Portugal raised in the four-year period between 2015 and 2018, with MSM accounting for 54.6% (1312/2403) of the cases in 2018. This sets up a baseline to guide the adoption of specific measures and the prioritisation of interventions. MSM should be given special attention when addressing new prevention strategies.

Genome-scale approach to study the genetic relatedness among Brucella melitensis strains.

Brucellosis is an important zoonotic disease that affects both humans and animals. To date, laboratory surveillance is still essentially based on the traditional MLVA-16 methodology and the associated epidemiological information is frequently scarce. Our goal was to contribute to the improvement of Brucella spp. surveillance through the implementation of a whole genome sequencing (WGS) approach. We created a curated ready-to-use species-specific wgMLST scheme enrolling a panel of 2656 targets (http://doi.org/10.5281/zenodo.3575026) and used this schema to perform a retrospective analysis of the genetic relatedness among B. melitensis strains causing human infection in Portugal (a country where brucellosis is an endemic disease) from 2010 to 2018. The strains showed a phylogenetic clustering within genotype II (25 out of 36) and IV (4 out of 36), and shared clades with strains isolated from countries with which Portugal has intense food trading, tourism and similar eating habits, such as Spain, Italy and Greece. In addition, our results point to the identification of strong associations between B. melitensis strains, likely underlying missed “outbreaks” as 22 out of the 36 strains showed genetic linkage with others. In fact, the applied gene-by-gene approach grouped these strains into six genetic clusters each one containing putative epidemiological links. Nevertheless, more studies will be needed in order to define the appropriate range of cut-offs (probable non-static cut-offs) that best illustrate the association between genetic linkage and epidemiological information and may serve as alerts for the health authorities. The release of this freely available and scalable schema contributes to the required technological transition for laboratorial surveillance of brucellosis and will facilitate the assessment of ongoing and future outbreaks in order to prevent the transmission spread.

Screening of Human Immunodeficiency Virus and Other Sexually Transmitted Infections in a Group of Sex Workers in Indoor Settings in the Porto Metropolitan Area

Early diagnosis is a crucial tool for containing the human immunodeficiency virus and other sexually transmitted infections, particularly in key populations such as sex workers. Despite its relevance, there is a gap considering epidemiological studies and interventions aimed at the monitoring and diagnosis of sexually transmitted infections in Portugal. The objectives of this study are: (i) to contribute to a better understanding of the epidemiology of sexually transmitted infections; and (ii) to evaluate the transfer of screening methods from clinical settings to the outreach context in hidden populations such as sex workers. The screening of sexually transmitted infections (human immunodeficiency virus 1/2, hepatitis B virus, hepatitis C virus, syphilis, chlamydia and gonorrhea) were carried out in a sample of 100 sex workers during the Porto G outreach intervention in the Metropolitan area of Porto, from September 2015 to September 2016. Six reactive cases for human immunodeficiency virus were identified, five of syphilis, eight of chlamydia and two of gonorrhea. No positive results were detected for hepatitis B virus and hepatitis C virus. The results were discussed considering the risk gradient and sexually transmitted infections vulnerability in the different sex workers' subgroups. The results of this study corroborate the need to promote comprehensive responses to populations most affected by the human immunodeficiency virus and other sexually transmitted infections, such as sex workers. Also, in this group, men who have sex with men and trans women have a higher prevalence than cis women. Intervention strategies should be informed by rigorous epidemiological studies. The adaptation of the screening methodology performed in a clinical setting to the proximity context has shown to be an innovative response in Portugal, especially in sentinel populations.

Mapping Geographical Patterns and High Rate Areas for Sexually Transmitted Infections in Portugal: A Retrospective Study Based on the National Epidemiological Surveillance System.

Monitoring disease variation using finer scales to identify high-rate communities is a critical aspect for precision public health and for efficient resource allocation. This study aimed to map the spatial patterns of chlamydia, gonorrhea, and syphilis; identify high-rate areas across Portuguese municipalities; and determine the association of these sexually transmitted infections (STIs) with socioeconomic deprivation, urbanicity level, and population density. The STI notifications at municipality level for the period 2015 to 2017 were obtained from Portugal's Epidemiologic Surveillance System (Sistema Nacional de Vigilância Epidemiológica). Spatial Bayesian models were used to calculate smoothed standardized notification rates, identify high- and low-rate areas and estimate associations (relative risk [RR], 95% credible intervals [95%CrI]). There were 4819 cases of chlamydia, gonorrhea, and syphilis reported, accounting for 15.3%, 33.2%, and 51.5% of the notifications, respectively. The STI notification rates were substantially higher in Porto and Lisbon Metropolitan Areas and concentrically disperse around those. Notification rates of the 3 STIs were strongly correlated (r > 0.8). Rates of gonorrhea (Q1-lowest density vs. Q5-highest RR, 2.10; 95% CrI, 1.08-4.25) and syphilis (RR, 3.16; 95% CrI, 2.00-5.13) were associated with population density. Notifications of chlamydia (Q1-least urban vs. Q5-most RR, 9.64; 95% CrI, 1.73-93.59) and syphilis (RR, 1.92; 95% CrI, 1.30-2.88) increased with urbanicity level. We also found that notification rates of gonorrhea were associated with socioeconomic deprivation (Q1-least vs. Q5-most deprived RR, 1.75; 95% CrI, 1.07-2.88). Wide spatial inequalities in STI notification rates were observed, which were predominantly concentrated in the 2 metropolitan areas of the country. Our findings can help guide more targeted interventions to reduce STIs incidence.

Large scale patterns of trematode parasite communities infecting Cerastoderma edule along the Atlantic coast from Portugal to Morocco

In this study, spatial sampling was performed from north Portugal to south Morocco to analyse trematode communities of the widespread bivalve Cerastoderma edule, host of several trematode species. From the twelve trematode species found in this study, nine were present in multiple aquatic systems demonstrating high trematode dispersal ability, driven by the presence of all hosts. Multivariate analysis related to trematode communities in cockles clustered: 1) Portuguese aquatic systems influenced by cold waters, leading to low trematode abundance; 2) coastal systems characterized by dominance of trematode Parvatrema minutum and muddy sediments; 3) lagoons (or bays) with high oceanic influence and high trematode diversity. These findings suggested that, besides host species presence, temperature is an important trigger for parasite infection, with coastal upwelling operating as a shield against trematode infection in Portugal and masking latitudinal gradients. Results highlighted the possible consequences of thermal modification mediated by oceanographic global circulation change on cockle populations.

Failure to complete treatment for latent tuberculosis infection in Portugal, 2013-2017: geographic-, sociodemographic-, and medical-associated factors.

There is conflicting evidence about factors associated with failure to complete treatment (FCT) for latent tuberculosis infection (LTBI). We aim to identify the geographic, sociodemographic, and medical factors associated with FCT in Portugal, highlighting the two main metropolitan areas of Porto and Lisbon. We performed a retrospective cohort study including LTBI patients that started treatment in Portugal between 2013 and 2017. We calculated adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) using multivariable logistic regression to identify geographic, sociodemographic, and medical factors associated with FCT. Data on completion of treatment were available for 15,478 of 17,144 patients (90.3%). Of those, 2132 (13.8%) failed to complete treatment. Factors associated with FCT were being older than 15years (aOR, 1.65 (95% CI = 1.34-2.05) for those aged 16 to 29), being born abroad (aOR, 2.04 (95% CI = 1.19-3.50) for Asia; aOR, 1.57 (95% CI = 1.24-1.98) for Africa), having a chronic disease (aOR, 1.29 (95% CI = 1.04-1.60)), alcohol abuse (aOR, 2.24 (95% CI = 1.73-2.90)), and being intravenous drug user (aOR, 1.68 (95% CI = 1.05-2.68)). Three-month course treatment with isoniazid plus rifampicin was associated with decreased FCT when compared with 6- or 9-month courses of isoniazid-only (aOR, 0.59 (95% CI = 0.45-0.77)). In Lisbon metropolitan area, being born in Africa, and in Porto metropolitan area, alcohol abusing and being intravenous drug user were distinctive factors associated with FCT. Sociodemographic and medical factors associated with FCT may vary by geographical area and should be taken into account when planning interventions to improve LTBI treatment outcomes. This study reinforces that shorter course treatment for LTBI might reduce FCT.

Changes in emm types and superantigen gene content of Streptococcus pyogenes causing invasive infections in Portugal

Fluctuations in the clonal composition of Group A Streptococcus (GAS) have been associated with the emergence of successful lineages and with upsurges of invasive infections (iGAS). This study aimed at identifying changes in the clones causing iGAS in Portugal. Antimicrobial susceptibility testing, emm typing and superantigen (SAg) gene profiling were performed for 381 iGAS isolates from 2010–2015. Macrolide resistance decreased to 4%, accompanied by the disappearance of the M phenotype and an increase of the iMLSB phenotype. The dominant emm types were: emm1 (28%), emm89 (11%), emm3 (9%), emm12 (8%), and emm6 (7%). There were no significant changes in the prevalence of individual emm types, emm clusters, or SAg profiles when comparing to 2006–2009, although an overall increasing trend was recorded during 2000–2015 for emm1, emm75, and emm87. Short-term increases in the prevalence of emm3, emm6, and emm75 may have been driven by concomitant SAg profile changes observed within these emm types, or reflect the emergence of novel genomic variants of the same emm types carrying different SAgs.

Performance of surveillance case definitions for respiratory syncytial virus infections through the sentinel influenza surveillance system, Portugal, 2010 to 2018.

BackgroundWell-established influenza surveillance systems (ISS) can be used for respiratory syncytial virus (RSV) surveillance. In Portugal, RSV cases are detected through the ISS using the European Union (EU) influenza-like illness (ILI) case definition.AimTo investigate clinical predictors for RSV infection and how three case definitions (EU ILI, a modified EU acute respiratory infection, and one respiratory symptom) performed in detecting RSV infections in Portugal.MethodsThis observational retrospective study used epidemiological and laboratory surveillance data (October 2010–May 2018). Associations between clinical characteristics and RSV detection were analysed using logistic regression. Accuracy of case definitions was assessed through sensitivity, specificity, and area under the receiver operating characteristic curve (AUC). A 0.05 significance level was accepted.ResultsThe study involved 6,523 persons, including 190 (2.9%) RSV cases. Among 183 cases with age information, RSV infection was significantly more frequent among individuals < 5 years (n = 23; 12.6%) and ≥ 65 years (n = 45; 24.6%) compared with other age groups (p < 0.0001). Cough (odds ratio (OR): 2.4; 95% confidence interval (CI): 1.2–6.5) was the best RSV-infection predictor considering all age groups, while shortness of breath was particularly associated with RSV-positivity among ≤ 14 year olds (OR: 6.7; 95% CI: 2.6–17.4 for 0–4 year olds and OR: 6.7; 95% CI: 1.5–28.8 for 5–14 year olds). Systemic symptoms were significantly associated with RSV-negative and influenza-positive cases. None of the case definitions were suitable to detect RSV infections (AUC = 0.51).ConclusionTo avoid underestimating the RSV disease burden, RSV surveillance within the Portuguese sentinel ISS would require a more sensitive case definition than ILI and, even a different case definition according to age.

Emergence of community-acquired methicillin-resistant Staphylococcus aureus EMRSA-15 clone as the predominant cause of diabetic foot ulcer infections in Portugal.

Methicillin-resistant Staphylococcus aureus (MRSA) are often found in infected diabetic foot ulcers, in which the prevalence may reach 40%. These complications are one of the main causes of morbidity in diabetic patients. The objectives of this study were to investigate the prevalence and antimicrobial resistance of MRSA strains in infected diabetic foot ulcers and to characterize their genetic lineages. Samples collected from 42 type 2 diabetic patients, presenting infected foot ulcers, were seeded onto ORSAB plates with 2mg/L of oxacillin for MRSA isolation. Susceptibility to 14 antimicrobial agents was tested by the Kirby-Bauer disk diffusion method. The presence of resistance genes, virulence factors, and the immune evasion cluster system was studied by PCR. All isolates were characterized by MLST, accessory gene regulator (agr), spa, and staphylococcal chromosomal cassette mec (SCCmec) typing. Twenty-five MRSA strains were isolated. All isolates showed resistance to penicillin and cefoxitin. Sixteen isolates showed phenotypic resistance to erythromycin being 7 co-resistant to clindamycin. Resistance to trimethoprim-sulfamethoxazole was found in 2 isolates harboring the dfrA and dfrG genes. The IEC genes were detected in 80% of isolates, 16 of which were ascribed to IEC-type B. Isolates were assigned to 12 different spa types. The MLST analysis grouped the isolates into 7 sequence types being the majority (68%) ascribed to SCCmec type IV. In this study, there was a high prevalence of the EMRSA-15 clone presenting multiple resistances in diabetic foot ulcers making these infections complicated to treat leading to a higher morbidity and mortality in diabetic patients.

Geospatial analysis applied to seroepidemiological survey of canine leishmaniosis in east-central Portugal

Despite the high prevalence of canine Leishmania infantum infection in Portugal, significant differences associated with different risk factors can be found between geographically contiguous areas. In this study, a geographical area within the central region of Portugal (municipalities of Proença-a-Nova, Mação and Vila de Rei) was investigated. An epidemiological survey involved the analysis by an indirect enzyme-linked immunosorbent assay of serum samples collected during the anti-rabies vaccination campaign from 282 dogs. Geospatial analysis showed the distribution of geospatial prevalence of leishmaniosis and has delimited two areas (clusters) with a statistically significant higher risk of seropositivity in dogs (p = 0.003 and p = 0.027, for clusters 1 and 2, respectively). The highest seroprevalence (56.0%; CI: 41.2–70.0) was found in Vila de Rei. Five land occupation types showed a possible influence on the geographic distribution of seropositivity, with statistically significant differences between seropositive and seronegative dogs. Land occupied by temporary irrigated crops (p = 0.026), olive groves (p = 0.013), complex cultural systems and parcelling (p = 0.021), open forests, logging and new plantations (p = 0.043) and watercourses (p = 0.012) influenced the geographical distribution of canine Leishmania infection. Seropositive dogs had a greater average area of occupied land (i.e. open forests, logging and new plantations) than the seronegative ones (3.1439 km2 versus 2.5650 km2, respectively; p = 0.043).

Recurrent maternal CMV infection associated with symptomatic congenital infection: results from a questionnaire study in Portugal

ObjectiveHuman cytomegalovirus (CMV) is the most widespread agent of congenital infection in humans and is still a challenging issue. Despite lower rates of vertical transmission being associated with recurrent infection...

Community- and Hospital-Acquired Klebsiella pneumoniae Urinary Tract Infections in Portugal: Virulence and Antibiotic Resistance.

Klebsiella pneumoniae is a clinically relevant pathogen and a frequent cause of hospital-acquired (HA) and community-acquired (CA) urinary tract infections (UTI). The increased resistance of this pathogen is leading to limited therapeutic options. To investigate the epidemiology, virulence, and antibiotic resistance profile of K. pneumoniae in urinary tract infections, we conducted a multicenter retrospective study for a total of 81 isolates (50 CA-UTI and 31 HA-UTI) in Portugal. The detection and characterization of resistance and virulence determinants were performed by molecular methods (PCR, PCR-based replicon typing, and multilocus sequence typing (MLST)). Out of 50 CA-UTI isolates, six (12.0%) carried β-lactamase enzymes, namely blaTEM-156 (n = 2), blaTEM-24 (n = 1), blaSHV-11 (n = 1), blaSHV-33 (n = 1), and blaCTX-M-15 (n = 1). All HA-UTI were extended-spectrum β-lactamase (ESBL) producers and had a multidrug resistant profile as compared to the CA-UTI isolates, which were mainly resistant to ciprofloxacin, levofloxacin, tigecycline, and fosfomycin. In conclusion, in contrast to community-acquired isolates, there is an overlap between virulence and multidrug resistance for hospital-acquired UTI K. pneumoniae pathogens. The study is the first to report different virulence characteristics for hospital and community K. pneumoniae pathogens, despite the production of β-lactamase and even with the presence of CTX-M-15 ESBL, a successful international ST15 clone, which were identified in both settings. This highlights that a focus on genomic surveillance should remain a priority in the hospital environment.

Dominance of vaccine serotypes in pediatric invasive pneumococcal infections in Portugal (2012\u20132015)

We evaluated the impact of continued 13-valent pneumococcal conjugate vaccine (PCV13) use in the private market (uptake of 61%) in pediatric invasive pneumococcal disease (pIPD) in Portugal (2012–2015). The most frequently detected serotypes were: 3 (n = 32, 13.8%), 14 (n = 23, 9.9%), 1 (n = 23, 9.9%), 7F (n = 15, 6.4%), 19A (n = 13, 5.6%), 6B and 15B/C (both n = 12, 5.2%), and 24F, 10A and 12B (all with n = 10, 4.3%). Taken together, non-PCV13 serotypes were responsible for 42.2% of pIPD with a known serotype. The use of PCR to detect and serotype pneumococci in both pleural and cerebrospinal fluid samples contributed to 18.1% (n = 47) of all pIPD. Serotype 3 was mostly detected by PCR (n = 21/32, 65.6%) and resulted from a relevant number of vaccine failures. The incidence of pIPD varied in the different age groups but without a clear trend. There were no obvious declines of the incidence of pIPD due to serotypes included in any of the PCVs, and PCV13 serotypes still accounted for the majority of pIPD (57.8%). Our study indicates that a higher vaccination uptake may be necessary to realize the full benefits of PCVs, even after 15 years of moderate use, and highlights the importance of using molecular methods in pIPD surveillance, since these can lead to substantially increased case ascertainment and identification of particular serotypes as causes of pIPD.

PGI37 - UNIVERSAL ACCESS TO DIRECT-ACTING ANTIVIRALS FOR THE TREATMENT OF HEPATITIS C MANAGED BY THE HOSPITAL PHARMACY: CONTRIBUTIONS TO PUBLIC HEALTH AND PUBLIC EXPENDITURE

Universal access to direct-acting antivirals (DAA) for the treatment of hepatitis C virus (HCV) infection in Portugal is in place since February 2015. The aim of this study was to estimate the long-term effect of this policy for the population of patients monitored by Centro Hospitalar e Universitário de Coimbra (CHUC) until May 2018. Data on age, gender, metavir, genotype, risk behaviours, previous treatment experience and prescribed DAA were registered for all patients with central authorized treatment since February 2015. A discrete-time Markov model was used to estimate the lifetime impact of the new policy on mortality, morbidity and related costs. Mortality endpoints considered were life expectancy and liver-related death. Morbidity was expressed in terms of cirrhosis cases, hepatocellular carcinoma (HCC) and liver transplant (LT). Only direct costs incurred by the Portuguese NHS were calculated. A total of 1000 patients were included in this study. Average age of the population was 50.5 years and 76.9% were male. The majority of patients had genotype 1 HCV (65.3%), were treatment naïve (67.6%) and metavir F1 (35.6%). Regimens containing sofosbuvir accounted for 89.2% of the treatments. Treatment with DAA is expected to increase life expectancy by 6.4 years/patient, up to an average 28.8 years lived after treatment initiation. In the long run the burden of related liver disease can be decrease by 355 premature deaths, 549 cases of cirrhosis, 198 cases of HCC and 35 cases of LT. This would result into net public expenditure savings of 28.3 million euros, 23 million (82%) of which due to non-progression to advanced liver disease. Universal access to new generation direct-acting antivirals may contribute to a substantial reduction in the burden of hepatitis C and overwhelming reduction in Portuguese NHS expenditures to treat advanced liver disease.

Demographic characterization and spatial cluster analysis of human Salmonella 1,4,[5],12:i:- infections in Portugal: A 10year study.

Salmonella 1,4,[5],12:i:- is presently considered one of the major serovars responsible for human salmonellosis worldwide. Due to its recent emergence, studies assessing the demographic characterization and spatial epidemiology of salmonellosis 1,4,[5],12:i:- at local- or country-level are lacking. In this study, a analysis was conducted over a 10year period, from 2000 to the first quarter of 2011 at the Portuguese National Laboratory in Portugal mainland, with a total of 215 Salmonella 1,4,[5],12:i:- serotyped isolates obtained from human infections by a passive surveillance system. Data regarding source, year and month of sampling, gender, age, district and municipality of the patients were registered. Descriptive statistical analysis and a spatial scan statistic combined with a geographic information system were employed to characterize the epidemiology and identify spatial clusters. Results showed that most districts have reports of Salmonella 1,4,[5],12:i:-, with a higher number of cases at the Portuguese coastland, including districts like Porto (n=60, 27.9%), Lisboa (n=29, 13.5%) and Aveiro (n=28, 13.0%). An increased incidence was observed in the period from 2004 to 2011 and most infections occurred during May and October. Spatial analysis revealed 4 clusters of higher than expected infection rates. Three were located in the north of Portugal, including two at the coastland (Cluster 1 [RR=3.58, p≤0.001] and 4 [RR=10.42 p≤0.230]), and one at the countryside (Cluster 3 [RR=17.76, p≤0.001]). A larger cluster was detected involving the center and south of Portugal (Cluster 2 [RR=4.85, p≤0.001]). The present study was elaborated with data provided by a passive surveillance system, which may originate an underestimation of disease burden. However, this is the first report describing the incidence and the distribution of areas with higher risk of infection in Portugal, revealing that Salmonella 1,4,[5],12:i:- displayed a significant geographic clustering and these areas should be further evaluated to identify risk factors in order to establish prevention programs.

Streptococcus agalactiae Causing Neonatal Infections in Portugal (2005-2015): Diversification and Emergence of a CC17/PI-2b Multidrug Resistant Sublineage.

The molecular characterization of 218 GBS isolates recovered from neonatal invasive infections in Portugal in 2005–2015 revealed the existence of a small number of genetically distinct lineages that were present over a significant time-span. Serotypes III and Ia were dominant in the population, together accounting for >80% of the isolates. Clonal complex 17 included 50% of all isolates, highlighting the importance of the hypervirulent genetic lineage represented by serotype III ST17/rib/PI-1+PI-2b. Serotype Ia was represented mainly by ST23, previously reported as dominant among invasive disease in non-pregnant adults in Portugal, but also by ST24, showing an increased frequency among late-onset disease. Overall erythromycin resistance was 16%, increasing during the study period (p < 0.001). Macrolide resistance was overrepresented among CC1 and CC19 isolates (p < 0.001 and p = 0.008, respectively). While representatives of the hypervirulent CC17 lineage were mostly susceptible to macrolides, we identified for the first time in Europe a recently emerging sublineage characterized by the loss of PI-1 (CC17/PI-2b), simultaneously resistant to macrolides, lincosamides, and tetracycline, also exhibiting high-level resistance to streptomycin and kanamycin. The stability and dominance of CC17 among neonatal invasive infections in the past decades indicates that it is extremely well adapted to its niche; however emerging resistance in this genetic background may have significant implications for the prevention and management of GBS disease.

Serious fungal infections in Portugal.

There is a lack of knowledge on the epidemiology of fungal infections worldwide because there are no reporting obligations. The aim of this study was to estimate the burden of fungal disease in Portugal as part of a global fungal burden project. Most published epidemiology papers reporting fungal infection rates from Portugal were identified. Where no data existed, specific populations at risk and fungal infection frequencies in those populations were used in order to estimate national incidence or prevalence, depending on the condition. An estimated 1,510,391 persons develop a skin or nail fungal infection each year. The second most common fungal infection in Portugal is recurrent vulvovaginal candidiasis, with an estimated 150,700 women (15-50years of age) suffering from it every year. In human immunodeficiency virus (HIV)-infected people, oral or oesophageal candidiasis rates were estimated to be 19.5 and 16.8/100,000, respectively. Candidaemia affects 2.19/100,000 patients, in a total of 231 cases nationally. Invasive aspergillosis is less common than in other countries as chronic obstructive pulmonary disease (COPD) is uncommon in Portugal, a total of 240 cases annually. The estimated prevalence of chronic pulmonary aspergillosis after tuberculosis (TB) is 194 cases, whereas its prevalence for all underlying pulmonary conditions was 776 patients. Asthma is common (10% in adults) and we estimate 16,614 and 12,600 people with severe asthma with fungal sensitisation and allergic bronchopulmonary aspergillosis, respectively. Sixty-five patients develop Pneumocystis pneumonia in acquired immune deficiency syndrome (AIDS) and 13 develop cryptococcosis. Overall, we estimate a total number of 1,695,514 fungal infections starting each year in Portugal.

Dalbavancin: A New Pathway for the Treatment of Acute Bacterial Skin and Skin Structure Infections in Portugal

Background: Acute bacterial skin and skin structure infections are frequent in-hospital infections. Vancomycin and linezolid are antibacterial agents commonly used in serious acute bacterial skin and skin structure infections but have been associated to prolonged length of stay. Dalbavancin is a new lipoglycopeptide antibacterial, active against Gram positive pathogens, with a long half-life, allowing for a single infusion of 1500 mg or 1000 mg followed one week later by 500 mg. The aim of this study was to assess the effect of dalbavancin on length of stay and mortality of acute bacterial skin and skin structure infections patients in Portugal.Methods and findings: we have modelled the natural history and treatment implications of acute bacterial skin and skin structure infections using a decision analytical tree that calculated the probability of success, failure or death for dalbavancin and linezolid. Efficacy endpoints were obtained from a randomized controlled trial. LOS and mortality due to acute bacterial skin and skin structure infections were derived from non-experimental studies.Conclusion: we estimated the average length of stay for dalbavancin in 10.4 days. Compared to linezolid this represents a 9.4 day reduction. Dalbavancin is estimated to decrease the death rate by 1.7% in serious acute bacterial skin and skin structure infections caused by Gram positive pathogens and by 1.8% in acute bacterial skin and skin structure infections caused by methicillin-resistant Staphylococus aureus.

Infeção VIH: Epidemiologia, História Natural e Diagnóstico

Ao longo dos últimos 35 anos, grandes progressos foram alcançados em termos de prevenção, diagnóstico e tratamento de infeção VIH, com redução da incidência de infeção em Portugal, na última década. Ainda assim, continua a existir uma taxa elevada de doentes com diagnóstico tardio, com consequências individuais e populacionais. Este artigo tem como objetivos: apresentar um ponto de situação da infeção VIH em Portugal, rever brevemente a evolução natural da infeção e explicitar o mais recente algoritmo de diagnóstico de infeção VIH, revisto em 2014, reforçando a necessidade de manter um elevado nível de suspeição clínica para o diagnóstico precoce de infeção.

Pneumocystis Pneumonia in 107 HIV Infected Patients Admitted to the Department of Infectious Diseases at Santa Maria Hospital, Lisbon (2002 - 2013)

Pneumocystis jirovecii pneumonia remains one of the most common opportunistic illnesses in patients infected with the human immunodeficiency virus. It is currently the most reported AIDS-defining infection in Portugal. The aims of this study were to analyze the features of a human immunodeficiency virus /Pneumocystis jirovecii pneumonia coinfected population, to compare it with the current literature, and to evaluate comparatively subpopulations of patients based on the previous knowledge of the human immunodeficiency virus infection, Pneumocystis jirovecii pneumonia diagnostic method and discharge results. A retrospective, observational, non-controlled study was conducted. The 107 patients admitted to the Department of Infectious Diseases at Santa Maria Hospital, in Lisbon, between the 1st of January 2002 and the 31st of December 2013, that presented the simultaneous diagnosis of human immunodeficiency virus infection and Pneumocystis jirovecii pneumonia were included. We studied epidemiologic and clinical data collected from the patient files, including immunity status, human immunodeficiency virus viral load and treatment options. The variables were analyzed using the Chi-Squared and Mann-Whitney tests. Data from this population evidenced male predominance (81.3%), patient age between 20 - 39 years old in 59.2% and heterossexual human immunodeficiency virus transmission in 48.6%; 24.3% were immigrants. Human immunodeficiency virus infection was previously known in 62.6% patients, but 76.2% were not engaged in medical care. A TCD4+ cell count ≤ 200 cells/mm3, high viral load and oropharyngeal candidiasis (72%) were prevalent risk factors associated with the Pneumocystis jirovecii pneumonia infection; hypoxaemia (78.5%) and LDH (82.2%), which are markers of Pneumocystis jirovecii pneumonia severity, did not translate into a worse prognosis. Pneumocystis jirovecii was only identified in 55.1% patients, pointing out the hardship involved in achieving a definite diagnosis. The inicial drug of choice was TMP-SMX (91.6%), and corticosteroid adjuvant therapy was added in 75.7%. The in-hospital mortality was 13.1%. The comparative analysis between groups of patients showed that injection drug users knew more frequently their human immunodeficiency virus seropositivity before the current hospitalization, which could be explained by the presence of specific programs aiming the early human immunodeficiency virus diagnosis in this population. However, there is lack of adhesion to the treatment and follow up consultations, putting them at a higher risk of Pneumocystis jirovecii pneumonia infection and other AIDS related diseases. Besides showing the classic Pneumocystis jirovecii pneumonia presentation, healthcare seeking was delayed, especially amongst patients with newly diagnosed human immunodeficiency virus infection. Moreover, the Pneumocystis jirovecii pneumonia diagnosis was difficult to obtain, mainly because of the current limitations of Pneumocystis jirovecii pneumonia diagnostic techniques, the simultaneous presence of other respiratory diseases, and the need of a high degree of clinical suspicion. This population of human immunodeficiency virus and Pneumocystis jirovecii pneumonia coinfected patients shows similarities with the data from previous studies, particularly considering Portuguese epidemiological data. The main differences found were the Pneumocystis jirovecii pneumonia diagnostic frequence in injection drug users, the importance of previous/recurrent episodes of Pneumocystis jirovecii pneumonia as a risk factor and the frequency of concurrent pulmonary diseases. The deceased patients showed less imagiologic features suggestive of Pneumocystis jirovecii pneumonia, and advanced age was found to be an indicative of worst prognosis.